Gout is a crystal deposition disease caused by raised levels of uric acid in the blood (hyperuricaemia) with persistence of hyperuricemia at levels higher than a serum saturation of 6.8 mg/dl leads to formation of monosodium urate (MSU) crystals and their deposition in joints and other tissues. However, only a minority of individuals with elevated serum uric acid (sUA) levels ever develop gout, emphasizing the importance of other factors in determining crystal formation including Genetics, Gender, age, Diet and alcohol intake, Obesity, some medications and medical conditions a correct diagnosis of gout is essential for the appropriate management, in 2011 the European League Against Rheumatism (EULAR) published an updated evidence based recommendations for diagnosis of gout. Although gout is well understood condition and good therapeutic options are available, it tends to be poorly managed, so The 2012 The American College of Rheumatology (ACR) guidelines for Management of Gout were designed to emphasize safety and quality of therapy and to reflect best practice. New approaches to urate lowering have led to mechanism-based therapies such as: non-purine, selective inhibitor of xanthine oxidase, URAT-1 inhibitors and a recombinant chimeric mammalian uricase. Three IL-1β antagonists - anakinra, rilonacept and canakinumab are being evaluated as an emerging therapies for gout.

Background
Obesity-induced limitations of the cardiopulmonary and the metabolic systems, resulting in exertional dyspnea, contribute to the limitations in the functional capacity frequently observed in obese individuals. In addition, the sedentary lifestyle often adopted by these individuals further compounds and contributes to impaired exercise tolerance.
Aim of the study
The current study was conducted to detect the effect of lifestyle modification in the form of weight reduction by diet and aerobic exercise on walking and physical performance.
Patients and methods
Twenty obese participants were included in this study. Their ages ranged from 25 to 43 years. All participants were evaluated before the first session of physical therapy program and at the end of the program after 2 months of exercise and a low-caloric diet of 25 kcal/kg actual weight/day through physical evaluation, which included anthropometric measurements, BMI, inspiratory capacity, and a physical performance test, which includes four tests (15-m rapid walking test, a timed up-and-go test, and stair climbing and stair descending tests).
Results
Analysis of data revealed significant improvement in the parameters assessed as follows: weight decreased from 81.3 ± 8.5 to 68.00 ± 4.50 kg (P ≤ 0.001); BMI decreased from 29.8 ± 2.0 to 24.1 ± 2.0 kg/m 2 (P ≤ 0.001); waist circumference decreased from 120.3 ± 14.4 to 112.3 ± 9.6 cm (P = 0.053); hip circumference decreased from 121.3 ± 6.1 to 112.6 ± 11.4 cm (P = 0.009); inspiratory capacity increased from 14.4 ± 2.7 to 21.0 ± 2.3 s (P ≤ 0.001); time of 15 m walk decreased from 21.2 ± 1.7 to 15.5 ± 2.1 s; timed up-and-go test decreased from 24.1 ± 2.8 to 15.3 ± 2.3 s; stair climbing time decreased from 45.3 ± 6.5 to 34.2 ± 2.6 s; stair descending time decreased from 36.2 ± 2.3 to 27.2 ± 2.1 s. Hence, the total physical performance increased from 31.9 ± 10.3 to 23.0 ± 8.5 s (P ≤ 0.001) and consequently improved the quality of life.
Conclusion
Lifestyle modification in the form of a low-caloric diet accompanied by exercise has a positive effect on physical performance and consequently on the quality of life.

Correlation of serum visfatin level with chest pain scoring as an indication of myocardial ischemia in chronic kidney disease patients

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Mohamed F Almaghraby, Abeer A MahmoudDOI:10.4103/1110-7782.139520

Background
Nicotinamide phosphoribosyltransferase (Visfatin), an enzyme involved in the NAD+ salvage pathway, has been shown to help in the regulation of glucose homeostasis. It is a highly conserved, 52 kDa protein found in living species from bacteria to humans. It is an adipokine produced and secreted primarily by adipose tissue. Chronic kidney disease (CKD) and end-stage renal disease patients showed increased cardiovascular mortality, and vascular events account for more than half of the deaths in this population. Myocardial ischemia is a consequence of coronary heart disease. Recent studies found that with increasing visfatin levels, CKD patients have a larger number of vessels with stenosis and a higher likelihood of coronary artery disease.
Research design and methods
The current prospective study includes 137 CKD patients and patients with chest pain (CP), as well as 20 patients as controls. Patient data included age, sex, comorbidities, smoking status, weight, height, and BMI, calculated using the equation: BMI = weight (kg)/height (m 2 ). Estimated glomerular filtration rate was calculated using the modified Modification of Diet in Renal Disease equations; in addition, enzyme-linked immunosorbent assay was used to estimate serum visfatin levels, and CP was assessed through a modification of the master questionnaire.
Results
All patients had significantly (P < 0.05) higher serum visfatin levels compared with controls. Patients who had typical anginal CP had significantly (P < 0.05) higher serum visfatin levels compared with those who had atypical anginal or nonanginal CP, with nonsignificantly (P > 0.05) higher serum visfatin levels in patients with atypical anginal CP compared with those with nonanginal CP. Moreover, patients with stage 4 CKD had a significantly (P < 0.05) higher serum visfatin level compared with patients with stage 3 CKD.
Conclusion
It could be concluded that patients with CKD are at an actual risk of developing CP secondary to myocardial ischemic attack, presenting either as typical or as atypical anginal pain. Elevated serum visfatin levels may be the cornerstone for the relationship between CKD and coronary heart disease. Serum visfatin levels in range of 12.4-16.4 ng/ml could predict the possibility of developing an anginal attack in patients with atypical anginal CP, with high sensitivity and specificity for diagnosis.

Background
Spontaneous infection of ascites is a severe complication of ascites and must be actively searched for. Many studies have been carried out on inflammatory markers and their levels in serum and ascitic fluid such as complement 3 (C3), complement 4 (C4), high-sensitive C-reactive protein (CRP), and procalcitonin, and have identified their role in the diagnosis of spontaneous bacterial peritonitis (SBP). The aim of our study was to measure and compare the serum and ascitic fluid levels of procalcitonin, high-sensitive CRP, C3, and C4 in patients with SBP and patients without SBP.
Patients and methods
This case-control study was carried out on 10 patients with cirrhotic ascites who were admitted with SBP and 20 patients with cirrhotic ascites with no existing evidence of SBP. Serum and ascitic fluid levels of C3, C4, high-sensitive CRP, and procalcitonin were determined using the enzyme-linked immunosorbent assay method.
Results
The mean ± SD of the serum levels of C3, C4, high-sensitive CRP, and procalcitonin were 3.38 ± 2.12, 0.36 ± 0.25, 18.76 ± 6.37, and 136.79 ± 58.14, respectively, in group I, whereas their levels in group II were 2.04 ± 1.98, 0.36 ± 0.29, 16.80 ± 5.97, and 147.78 ± 58.65, respectively. The mean ± SD of their ascitic fluid levels were 0.21 ± 0.14, 1.84 ± 1.69, 1.96 ± 1.15, and 162.43 ± 82.51, whereas their levels in group II were 0.46 ± 1.01, 2.07 ± 1.93, 2.98 ± 5.90, and 180.51 ± 93.70, respectively. Surprisingly, all these results were statistically insignificant. However, an ascetic fluid polymorph nuclear leukocyte count higher than 200/mm 3 has sensitivity, specificity, positive predictive value, and negative predictive value of 100% in the diagnosis of SBP.
Conclusion
An ascitic polymorph nuclear leukocyte count higher than 200/ml was the accurate marker for the diagnosis of SBP.

Background
Nasal polyposis (NP) is a chronic inflammatory condition with no proved effective long-term treatment and a tendency to recur.
Aim
The aim of our study was to evaluate the effect of immunotherapy on the recurrence rate of NP in atopic patients after surgical management and the ability to improve the quality of patients' lives and decrease their suffering.
Patients and methods
We chose 60 patients (discussion with the patients with respect to the benefits and hazards of the study was performed and informed consents were provided) with bilateral NP (as diagnosed by full history taking, clinical examination, nasal endoscopic examination, and sinonasal computed tomography) who proved to be allergic (by full history taking, clinical examination, skin prick test, serum total IgE, serum-specific IgE). We classified them into three groups: group I included 18 patients who underwent surgical management (functional endoscopic sinus surgery) as a control group, group II included 18 patients who underwent treatment with subcutaneous immunotherapy by gradual up-dosing protocol for inhalant allergens as a second control group, and group III included 20 patients who underwent treatment with subcutaneous immunotherapy for inhalant allergens 6 weeks after surgical treatment.
Results
In the three groups of patients, the sinoNasal Outcom -22 (SNOT-22) scores were significantly decreased (with the minimally important difference greater than 9 points in 17/18 patients in group I, 17/20 patients in group III, and 15/18 patients in group II), denoting significant clinical improvement in the three groups. However, patients treated with surgery and postsurgical immunotherapy reported more improvement, with no significant difference between them, than those treated with immunotherapy alone. Seven (38.9%) patients of group I had recurrence of NP, whereas six (30%) patients of group III had recurrence. On comparison, there was no statistically significant difference between the two groups. In group II, the NP score was declined on immunotherapy alone but did not disappear completely. The timing of recurrence of NP in patients of group I ranged from 7 to 13 months, whereas in group III it ranged from 12 to 16 months.
Conclusion
We found that immunotherapy could help in improving patients' clinical symptoms and subsequently their quality of life; postoperative immunotherapy in addition can delay the recurrence, although it does not decrease the recurrence rate significantly.

Introduction
Omentin-1 is a novel adipokine that has a pivotal role in modulating insulin sensitivity, immunity, and inflammation. Adipokines contribute directly to the atherosclerotic process. The current study was conducted to evaluate the serum omentin-1 level in type 2 diabetes mellitus (DM) patients and to evaluate its relationship with carotid intima media thickness (CIMT).
Patients and methods
Sixty participants were enrolled in the study: 30 patients with type 2 DM and 30 controls with normal glucose levels. Patients were classified into group I, which included 15 patients with CIMT greater than 0.9 mm, and group II, including 15 patients with CIMT less than 0.9 mm.
All groups were subjected to full medical history taking, clinical examination, and assessment of fasting blood glucose levels, lipid profile, and serum omentin-1 levels using enzyme-linked immunosorbent assay. BMI and CIMT were also assessed using color Doppler ultrasound.
Results
Serum omentin-1 levels were significantly decreased in patients with type 2 DM compared with controls and were further decreased in patients with increased CIMT.
Omentin-1 levels were negatively correlated with fasting blood sugar, BMI, waist circumference, lipid profile, and CIMT, and were positively correlated with high-density lipoprotein, with r-values of −0.72, −0.9, and −0.81 for fetal bovine serum, BMI, and CIMT, respectively; −0.58, −0.70, and −0.49 for triglyceride, low-density lipoprotein, and cholesterol, respectively; and +0.66 for high-density lipoprotein.
Conclusion
Serum omentin-1 level is decreased in type 2 DM patients and is negatively correlated with CIMT and BMI. Hence, omentin-1 could serve as a protective marker and predictor for cardiovascular disease. Further study needed to show whether omentin-1 is considered as a risk factor for DM.

Some risk factors of gallstone formation after laparoscopic sleeve gastrectomy and the role of ezetimibe versus ursodeoxycholic acid in its prevention

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Alaa Elgamal, Ahmad Tarek FawzyDOI:10.4103/1110-7782.139548

Aims
Obese patients are at increased risk for gallstones during rapid weight loss and after laparoscopic sleeve gastrectomy. The aims of this study were to evaluate the prophylactic effect of ursodeoxycholic acid and ezetimibe for prevention of gallstone formation after sleeve gastrectomy and to identify some risk factors.
Settings and design
This was a prospective randomized study conducted at Al Rashid Hospital, Kuwait.
Patients and methods
A total of 215 obese patients were included. Preoperative assessment was performed, including history, examination, obesity evaluation (body weight, BMI, waist circumference), full laboratory work, gastroscopy, and abdominal ultrasonography. After laparoscopic sleeve gastrectomy, patients were divided randomly into: group 1 (control), group 2 (ursodeoxycholic acid), and group 3 (ezetimibe). Patients were scheduled for 3-, 6-, and 12-month visits for assessment of % excess weight loss and abdominal ultrasonography.
Results
A significant reduction in gallstone formation was found in the ezetimibe group (5.5%) compared with the control group (17.6%). A statistically significant increase in % excess weight loss was observed in patients with gallstones (38.5%) versus patients without gallstones (28.2%). Percentage of gallstone formation during first 6 months postoperatively was double that during the next 6 months in both the control and treatment groups.
Conclusion
Risk of gallstone formation during the first 6 months after laparoscopic sleeve gastrectomy was double that during the second 6 months. Ezetimibe is effective in reducing relative risk by 70% and ursodeoxycholic acid by 50% versus control; hence, we recommend usage of one of these medications for 1 year postoperatively. Furthermore, we recommend more work on combining both medications together.

Background
Skin prick test (SPT) is a gold standard test for diagnosis of allergic [immunoglobulin E (IgE)] diseases. There is a subset of patients who have positive nasal provocation to allergens, despite having a negative SPT. The aim of our study was to evaluate SPT sensitivity in atopic patients with allergic nasal polyposis. We chose 56 patients (discussion with the patients regarding the benefits and hazards of the study was performed and informed consent was taken from them) with bilateral nasal polyposis (as diagnosed by full history taking, clinical examination, nasal endoscopic examination, and sinonasal computed tomography) who proved to be allergic (by full history taking, clinical examination, positive serum total IgE, serum-specific IgE, and tissue-specific IgE). SPT was performed using a panel of 37 allergen extracts.
Results
A total of 15 patients showed negative results to SPT representing 26.8%. In all, 41 patients showed positive results to SPT (73.2%); six patients (14.6%) showed positive result to only one allergen (monosensitized), whereas the remaining patients were polysensitized. The most common allergens found to be positive by SPT were: 'House Dust' with positive results in 19 patients representing 46.3% of patients with positive results to SPT (41 patients), followed by 'Pollens' with positive results in 18 patients (43.9%), 'House Dust Mite' with positive results in 17 patients (41.5%), and then 'Molds' with positive results in 14 patients (34.2%).
Conclusion
Negative SPT does not exclude allergy in atopic patients with nasal polyposis. Thus, before delivering a diagnosis of nonallergic rhinitis in patients with negative SPT to common allergen, further tests are needed. We recommend further studies to evaluate the prevalence, immunopathology, and management of local allergic rhinitis.

Atypical neurological presentations of hypothyroidism include myelopathy which has been seldom reported as presenting feature in patients. This case was one of those atypical presentations of hypothyroidism in which patient presented with neurological complication viz myelopathy which was timely diagnosed and treated. The symptoms including neurological findings reversed with thyroxin replacement. The case highlights the varied and vivid manifestations of hypothyroidism which treating physicians should be aware of while treating patients.

Although acute myocardial infarction commonly results from coronary atherothrombosis, there are several other etiologies that should be taken initially into account, especially in young adults without significant atherosclerotic risk factors. Thrombophilia and coronary arteritis are, in this context, examples of etiologies that should be looked after. Through this article, we present a case of Behçet's disease with arterial involvement diagnosed after myocardial infarction resulting from thrombosis of the left main coronary artery in a 38-year-old young man without any particular past medical history.

Anterior pituitary hypofunction is a well-known complication following snake bite. However, central diabetes insipidus as a complication of snake bite is only rarely reported in the literature. We are reporting a case of central diabetes insipidus, which developed as sequelae to viper bite.